e-Publications

In this guest blog for World Pneumonia Day on the 12th of
November, Dr. Agnes Binagwaho, Minister of Health, writes of Rwanda's
partnership with the GAVI Alliance to pioneer the Pneumococcal Vaccine.

In April 2009, Rwanda became the first low-income country to
rollout the pneumococcal vaccine (PCV7) through a partnership with Wyeth. This
was a great moment for us, for after having achieved dramatic reductions in
malaria incidence, pneumococcal disease had stood as the new leading cause of
death among Rwandan children. And it was the dedicated work of our
partner, The
GAVI Alliance for Vaccines, that ensured the pneumococcal vaccine
would be both accessible and affordable for use in our country.

Pneumonia remains the single largest cause of death among
children under five around the world. Every 20 seconds, a child dies of this
preventable disease.

On November 12, 2011, Rwanda will join other countries in observing
the third World Pneumonia Day, a day to celebrate the power of immunization to
save lives when access is assured.

The PCV7 vaccine also prevents against pneuomoccal meningitis, a
debilitating disease that leaves children who survive it with lifelong mental
and physical disabilities.

Certainly immunization is not the only way to prevent pneumonia;
breast-feeding, improved nutrition, and the reduction of indoor air pollution
are also essential, and children must have access to effective antibiotics when
they do fall sick. But immunization removes the burden of hospitalization and
treatment on the health system and diminishes the time . This is a major
economic advantage in countries like Rwanda, where the time lost by parents
lose from work in caring for their children. For immunization to work, it needs
to be integrated fully in health and community services. This is what we did in
Rwanda.

Last year, the pneumococcal vaccine was scaled up in 16
countries. By 2015, GAVI expects that 58 countries will have introduced the
latest generation pneumococcal vaccines nationwide, covering another 90 million
children. With sustained commitment among all partners, including both GAVI
countries and donor countries, we can achieve remarkable progress in the fight
against preventable deaths among children.

The number of lives saved by GAVI is a major contribution
towards the world’s pursuit of the fourth Millennium Development Goal, but we
must sustain the momentum. In Rwanda today, more than 80% of children have
access to the pneumococcal vaccine. The children whose lives are being saved
through our partnership with GAVI will help to build a Rwanda where health for
all is not simply a dream but one of the foundations of a strong, peaceful
nation of tomorrow.

I am proud
to say that Rwanda has made great strides in improving the health of our people
in the past decade. Our budgets for health and immunisation have steadily
increased, accompanied by a strong national health strategy that has been
endorsed by all the main actors in the health sector.

Babies
born in Rwanda now receive life-saving vaccines against tuberculosis,
diphtheria, tetanus, pertussis, polio, measles, Hib, hepatitis B and
pneumococcal disease. In 2009, 97% of the children in our country were given
the required three doses of the pentavalent vaccine.

Our
investments have paid off. Between 1990 and 2008, under-five mortality rates
dropped from 174 to 103 deaths per 1,000 live births. this success is linked to
a range of life-saving interventions, not least to immunisation.

Rwanda
knows that immunisation is a cost-effective investment in the future of our
children. Preventing disease is always better than waiting until children fall
sick. And because we want to sustain these achievements after GAVI support has
ended, we are committed to contributing financially to the vaccines we
introduce. Co-financing is an important step towards ensuring that we maintain
our current political ownership and commitment to reducing child mortality, and
achieve long-term sustainability of interventions.

Already in
2008, when co-financing of new GAVI vaccines became mandatory, our Government
decided to contribute significantly more than what was required by GAVI – us$
0.75 per dose instead of the compulsory us$ 0.15 per dose. Between 2008 and
2010, our co-payments amounted to nearly us$ 2.5million, or 26% of the total
GAVI vaccine support to Rwanda.

Although
Rwanda is a low-income country, we pay 100% of the cost of our existing
vaccines, such as those protecting against measles and polio, and we have
a solid plan for increasing our contribution to full funding for new vaccines
in the future. We are hoping to introduce rotavirus vaccines in 2012 and are
looking to protect women against cervical cancer by introducing human
papillomavirus (HPV) vaccines as soon as possible.

In
addition to vaccine support, GAVI funding helps us strengthen the health system
to deliver immunisation and other integrated high-impact services. our network
of local hospitals, health centres and outreach health workers has been
effective in encouraging improved hygiene, good nutrition and exclusive
breastfeeding – all of which help to combat disease. Immunisation is an
important entry point for these interventions, as well as for other initiatives
such as family planning, HIV testing, vitamin A supplementation, deworming and
bednet distribution.

Our
country is currently on track to achieve millennium development Goal 4 on
reducing child mortality. Whether we will succeed depends not only on continued
support from development partners, but also on our own commitment and
contribution. co-financing is one of the ways in which we seek to ensure that
we will continue to reap the benefits of our investments in health in the long
term.

Dr Agnes Binagwaho, Minister of Health of Rwanda and Dr Fidele
Ngabo, Director of Maternal and Child health in the Ministry of Health in
Rwanda and Ms Cynthia Kamikazi of the GAVI Alliance discuss a comprehensive new
program to eliminate cervical cancer in Rwanda.

In 2002, the Rwandan government set up a strategy to tackle
priority diseases that were the major killers of both adults (HIV/AIDS,
tuberculosis and malaria) and children (gastroenteritis, pneumonia, malaria,
meningitis and HIV).

For the past few years, anti-retroviral coverage for HIV patients
in need of treatment has increased from 10 percent in 2003 to 82% in 2010. The
rate of coverage for prevention of maternal-to-child transmission services has
reached 78% of pregnant women. Malaria incidence has declined by 70% between
2001 and 2010. In 2010, the cure rate for tuberculosis treatment was 87%. For
multi-drug resistant tuberculosis, the cure rate was 91 percent.

During the same year, 98% of TB patients were tested for HIV.
Other indicators of progress include 94% of children vaccinated against
pneumococcal disease, and community health workers treating gastroenteritis
without delay at village level.

Having met most of the targets set in regards to infectious
diseases, as well as achieving improvements in the heath system more generally,
Rwanda has noted an increase in life expectancy. As the population has begun to
live longer, chronic, non-communicable diseases, such as cancer, rheumatic
heart diseases, diabetes and hypertension are becoming more visible. And as a
result, the Ministry of Health has initiated a new strategy of tackling
priority chronic and non-communicable diseases, so as to continue to provide a
better and longer life to the Rwandan population. Cervical cancer is one of such
diseases.

According to research conducted in Rwanda, cervical cancer
accounts for 27% of all the women’s cancer in the two university hospitals. The
World Health Organization has reported that the incidence of cervical cancer in
Rwanda is 49 per 100,000 in the population.

Knowing the magnitude of cervical cancer, and the fact that
cervical cancer is one of the few cancers that can be fully prevented through
vaccination and screening, and treated in its early stages, the Government of
Rwanda decided to start their fight with a comprehensive program against
cervical cancer.

In light of this, the Ministry of Health, in collaboration with
its partners, has developed a national plan for prevention, screening and
treatment of cervical cancer in Rwanda. This comprehensive plan includes HPV
vaccination of girls aged 11 to 15, early detection of women aged between 35 to
45 years, as well as building in country the capacity to treat any stages of
cervical cancer according to different levels of the health system. Through the
work of the first lady, the Ministry of Health has negotiated with partners to
support this first ever national comprehensive plan for cervical cancer. As a
start, MERCK has donated 2 million HPV vaccine doses while QIAGEN has donated
250,000 HPV DNA-tests for screening.

It is in this light that on April, 26, the Government of Rwanda
officially launched a Rwandan comprehensive cervical cancer program. The
program started with vaccination of school girls in Primary 6, beginning with
the Kanyinya sector in Nyarugenge District, followed by 2 days of vaccination
in all primary schools in Rwanda, as well as a national summit on women’s
cancers.

In collaboration with the MINEDUC, the Ministry of Health has made
the HPV vaccine available to all health centers; and because 95% of girls are
enrolled in school during the ages targeted, all primary schools have been
identified as vaccination sites.

Using the national network of three community health workers per
village and the commitment of the local leaders, girls who did not attend
schools during the two days of vaccination have been identified at home and
vaccinated in the community. As a result, 94% of girls have received their
first dose of HPV vaccine while the rest will receive it during the catch-up
phase in collaboration with CHWs.

This comprehensive cervical cancer program will avail prevention,
screening and treatment for the entire population at risk. All of this will be
done for a period of 3 years, while Rwanda works on its sustainability plan
after this period.

The parents and community members interviewed during the
vaccination days were very happy to have an opportunity to prevent cancer among
their daughters, and there was an excellent adherence to this program on a
voluntary basis.

Rwanda is the first country in the world to offer a comprehensive
plan to eliminate cervical cancer despite social and economic challenges. The
Rwandan plan is for the country to be free from cervical cancer within 40 years
(by 2050) as a result of consistent vaccination, regular screening and timely
treatment.

Letter to the Global Fund from Dr Agnes
Binagwaho, Minister of Health, Rwanda

Letters to the Editor:
Responses to Auditing the Auditor

June 20,
2011

Global Fund Observer (GFO)

Firstly, I would like to give a word of thanks to a few members of
the OIG team who visited us in 2010 and who displayed a high level of
professionalism when interacting with the Rwandan teams. However, I would like
to share my disapproval of the behaviour of the other members of the OIG team
who were less than appropriate and very unprofessional at times during their
interaction with our teams – because sharing this may help shape the way audits
are performed by the OIG teams in the near future.

In Rwanda, while it is true that we are in a process to build the
capacity of our accountants, the approach used by some OIG team members was
undesirable and not called for. They undermined our accountants, behaved
unpleasantly and even in an insulting manner in certain instances. Though the
Team Leader stressed the importance of professionalism, respect and
collaboration during the audit exercise, these team members diverted from their
core mission and objectives and, instead, appeared to play a police rather than
an auditing role. Despite being proven wrong on some of the claims they made,
they continued repeating the same statements without taking into account
answers and clarifications provided to them.

The attitude of some members of the OIG team did not uphold the
human right for respect. They reminded us of how power can be abused. These
experts should have been more respectful. It was as if their motivation was to
find the flaws and see us fail the audit. Surprisingly, the team members I am
referring to never thought about apologizing for their inappropriate conduct.
However, I recognize that the Team Leader was continuously keen on trying to
ensure an atmosphere of respect and that a few members of the OIG team acted in
a professional and courteous manner; it is just a pity that, though key, they
were a minority in terms of numbers.

An audit should be done with a view to promote capacity building
rather than with an objective to prove you wrong. Its basis should be rooted in
good practices and lessons learnt for better performance. Until everyone
involved in these audits understands their objectives and the importance of
professionalism in conducting them, the OIG will have to monitor the behaviours
of his teams, including the subcontracted ones, as we hear unacceptable stories
from countries from the Southern constituency. This is critical, as we want to
continue seeing the OIG’s audits as opportunities to learn about our strengths
and weaknesses and improve the management of disease programs.

Monday, March 8 marked the celebration of International Women’s
Day, a global tribute to the economic, political and social achievements of
women past, present and future. In this guest post, Dr. Agnès Binagwaho,
Permanent Secretary of Rwanda’s Ministry of Health, reflects on the human rights
of women in Rwanda.

Sixteen years ago, during the 1994 Rwandan Genocide, perpetrated
by Hutu extremists against Tutsis and the Hutu moderates, where one million
people were killed — more than one tenth of the Rwandan population — women’s
rights were profoundly denied, as many of our mothers, sisters, and girls
endured systematic massive rape that resulted, often intentionally, in the
devastating effects of a slow death by HIV/AIDS infection. During that time the
country was destroyed, its health system ceasing to function as health
professionals were killed or left the country and infrastructure and materials
were destroyed. As this week we celebrated International Women’s Day 2010, I
salute the fact that rape as a weapon of war has been recognized as a crime
against humanity.

Times have changed in Rwanda. Thanks to the new leadership since
1994, most of the population thinks “out of the box,” with a strong belief that
there is always a solution if we work hard to find it and if we search for
solutions within our culture and within ourselves. In this short essay, I would
like to share how the situation during the time of the genocide has been
reversed to favor women rights and how it impacts my work.

Click here to continue reading Agnès Binagwaho’s piece,
“What do human rights mean for a working woman in the Rwandan health sector?
Reflections on International Women’s Day.”

Adolescents remain a neglected group in Rwanda’s health care model
according to a new report on adolescent health by Dr. Agnes Binagwaho,Permanent Secretary of Rwanda’s Ministry of Health. While the
country’s health care infrastructure has vastly improved since 1994, so that
vulnerable groups such as mothers, infants, and people living with HIV/AIDS
experience better health outcomes, few efforts focus on behavioral and
preventative health care for adolescents. Dr. Binagwaho argues that adolescents
are a neglected group in the country’s health care model primarily because they
are considered comparatively healthy with a low disease burden. Yet the choices
adolescents make today affect their health — and the health of their families —
in the future, especially as these choices relate to family planning and STDs.

The new report emerges from Dr. Binagwaho’s research on the gap
between the right of HIV-infected children to health services and the reality
in Rwanda. Finding little research or advocacy focused on adolescent health,
Dr. Binagwaho decided to undertake the task herself. She found that although
adolescents may be equipped with knowledge, they lack “life skills,” for
example, the ability to negotiate safer sex or to seek the help of family
planning services. She offers practical suggestions for addressing this gap,
including policy changes, training, and social support designed specifically
for adolescents.

The report’s Executive Summary is provided below. Her full report
on “Adolescent Health in Rwanda” is available here.

Executive Summary of the “Report on Adolescent Health in Rwanda,”
by Dr. Agnes Binagwaho

The Government of Rwanda, supported by outside partners, has been
able to significantly improve the health status and HIV services of the
population in the last decade. Life expectancy increased; infant, child and
maternal mortality has been reduced; and the spread of HIV/AIDS has been
contained. Nevertheless, there is still a lot of room for further improvement
of health care in Rwanda, in particular by increasing access to quality health
and HIV care services.

One area that has been widely neglected in Rwanda is the
adolescents health. A comprehensive strategy to advance health services
(including STIs and HIV prevention and treatment) that meet adolescent needs is
presently missing but absolutely in light of the fact that adolescents make up
about a third of Rwanda’s population.

Adolescents are often perceived as healthy, since they face a
relatively low disease burden. While this is true regarding traditional
measures of disease burden such as DALYs, adolescents impact their immediate
and their future health outcomes by their behavior today. Therefore, compared
to other age groups, adolescent health and HIV status are concerned with a
higher share of preventive and behavior changing health services compared to
curative health services.

The key health issues faced by Rwanda’s adolescents today are
related to reproductive health, including family planning, STIs and HIV – which
is particularly important given its public health implications. Mental health
and substance abuse are perceived as an important but less pressing health
concern in Rwanda. Injuries and accident-related traumas – often a main health
threat for adolescents in developed countries – seem to be less relevant in
Rwanda.

Several challenges to improve adolescent health and sexual and
reproductive health in particular, exist in Rwanda: Even though adolescents’
knowledge about protective health behavior and risk factors for poor health has
increased, there is a clear gap between knowledge and the ability to apply it
in critical situations – including situations that increase the risk of HIV
infection. A lack of independence and assertiveness, such as being able to
negotiate safer sex, is perceived as an obstacle to better health through
reduced risk behavior.

Despite an impressive rebuilding of the whole health care system
since 1994, youth-friendly health services are still widely missing. This is
true for all the component of a clinical program, such as infrastructures,
personnel trained to meet adolescents’ needs, and guidelines defining HIV
packages for this group. 43% of the children surveyed were treated with adults,
– 6 – not in a separate pediatric ward. Furthermore, 90.7% of children and
their parents stated that they felt the need for the establishment of an
adolescent ward. Finally, in a hierarchical society with strong roles and
norms, social pressure on adolescents regarding their behavior is another
factor that often hinders adolescent health seeking behavior. In particular if
HIV and family planning services are not used by adolescents due to fear of
social consequences, and in the absence of relevant information provided by
adult family members, this can lead to worse health outcomes.

Findings in this report indicate that:

1. Policies should ensure that adolescents not only receive
technical health and HIV information, but are also trained in how to apply this
knowledge in their daily life. To achieve adequate adolescent training and
education, health care providers have to be sensitized on this issue and
enabled to provide this kind of training.

2. To ensure adolescent access to high quality health and HIV
services, adequate guidelines infrastructures, and trained personnel must be
available to ensure that quality youth-friendly services can be offered.

3. Social support has to be ensured for adolescents. This should
include a very wide array of activities and interventions aimed at actively
engaging adolescents in changing social norms limiting their access to health
and HIV services. Messages concerning adolescent health, such as HIV and STI
prevention and treatment, should be included whenever possible in adolescent
related activities.

4. A national adolescent health policy should be developed as an
instrument to establish a common policy base between relevant ministries,
agencies, health partners and civil society – thereby ensuring the necessary
support to provide an implementation framework and to keep institutions
accountable. This policy should also define a national mechanism for
coordination between government institutions, as well as between government
agencies and partners working in adolescent health and HIV issues.

In addition to Dr. Binagwaho, Dr. Fidele Ngabo, Cathy Mugeni, and
Niloo Ratnayake also contributed writing to this post.

Access to care in resource-constrained countries has three major
barriers to overcome: finances, infrastructure, and geography. Community health
workers (CHWs) are an unavoidable solution for both infrastructure and
geography. The Government of Rwanda has recognized that CHWs are necessary in
order to improve access to health in rural communities. By using CHWs, with
their approach to health at the community level, Rwanda hopes to solve 80% of
health problems in the country.

Rwanda has set up a system where each village (100 to 150
households) elects two volunteers to act as CHWs for the general population.
Because each community votes on one woman and one man to serve the village in
this capacity, becoming a CHW is now a position of respect, raising gender
equity throughout Rwanda.

These two CHWs are then trained to monitor growth and development
in children, to care for people living with HIV, and to refer sick patients to
the nearest health facility. Their training is designed by the Ministry of
Health, which enables them to provide services in a harmonized manner
throughout the country. By sensitizing the local village and making themselves
available, they improve access to care; because of CHWs, a greater number of
previously unreachable Rwandan citizens now have access to care. The CHWs
trained this year to provide services to their villages are trained to treat
certain diseases using amoxicillin and to distribute family planning tools
(condoms, contraceptive pills, and injectable contraception). Read more

Participation as a developmental tool for
the health sector: The Rwandan experience

Participation is a right situated at the very heart of the human
rights vision. Participation holds this central place because it requires and
activates the full range of other human rights. People can only fully exercise
their right to participation if they are correctly informed and free to express
their views on the situation in which they live, the priorities that should be
emphasized, the actions to be taken, and the way in which those actions should
be implemented, followed-up, and evaluated.

My experiences as a manager of national public health programs
has taught me that no solid, lasting progress in health is possible without
applying the principle of participation. I would like to illustrate this point
through several examples that have an impact on my daily work.

In 1994, the genocide in Rwanda completely devastated our health
system. The infrastructure was destroyed. Human resources were drastically
diminished by the massacres and by the departure of people who either feared
being killed or were taken hostage by the genocidaires as they fled.

Today, 15 years later, we still have a long road ahead, to build
the optimal health system for our country. We are far from declaring ourselves
satisfied. However, we have managed not only to recoup the losses of the
genocide period but to improve substantially on what existed before 1994.

Our health indicators show that we are on the right path in our
construction of a robust health system based on the principle of universal
access to health, with a special focus on the most vulnerable individuals.

Presently, in Rwanda:

Health insurance now covers 92% of
all Rwandans, including 83% at community level;

The uptake of curative care has
tripled;

Vaccination now covers more than
90% of children;

Malaria mortality has been reduced
by 2/3; and

70% of HIV-positive people in need
of ARV treatment are receiving it.

To reach this result, we have relied on the effective
contribution of all of our people — thus we have relied on participation.

The involvement of all stakeholders means that communities,
civil society, and both the private and public sectors are involved.

For the community sector, participation is enabled through
massive information campaigns on the right to health and through training. We
raise awareness about people’s responsibility to participate in goal setting,
decision making, and the fight for transparency and against corruption. The
goal is for each dollar to buy the greatest possible amount of health while
respecting equity.

This is written into Rwanda’s Community Health Policy: “Community
Health is seen as a holistic and integrated approach that takes into account
the full involvement of communities in planning, implementation and evaluation
processes, and assumes communities to be an essential determinant of health and
the indispensable ingredient for effective public health practice.”

The principle of participation is also applied in the public
sector. The public sector departments of education, infrastructure, roads,
energy, water, finance, social issues, gender, foreign policy, cooperation, and
so forth must all participate actively in the work of the health sector if we
want health action to respond effectively to demand. The requirement for
participation is included in the “Manual of Procedure of the Ministerial
Cabinet,” which stipulates that no policy, ministerial instruction, or
legislative proposal can be discussed in the Cabinet without ensuring that all
those constituencies who may be affected have been informed and have actively
participated in developing the proposal to be discussed.

With civil society and the private sector, the lessons drawn
from their active, synergistic participation in the response to the HIV
pandemic have recently been expanded to the whole of the health sector.

The fight against HIV/AIDS is based on the concept of GIPA:
“Greater Involvement of People Living with HIV/AIDS: Never do for us without
us.” In each of nine sub-sectors — PLWHA, faith-based organizations,
community-based organizations, transportation, media, the private sector,
people living with disabilities, and young people and women — Rwandan NGOs have
formed what we term “umbrella” groups to enable and coordinate participation.
These groups have identified representatives who can speak for their interests
in each district and at the central government level.

Today, the nine umbrella organizations involved have transformed
themselves into “Umbrellas for the fight against HIV/AIDS and the promotion of
health.” Their representatives participate in decision making, planning,
follow-up, and the evaluation of health sector activities at the district and
central levels.

We all know that a healthy population accelerates development. I
hope that I have been able to show you why, on Rwanda’s path to development,
the urgency of action makes the principle of participation in the health sector
indispensable. Health is also coordinating with other sectors. For
participatory efforts to be effective and sustainable, they must be anchored
institutionally and taken forward using a multi-sectoral approach.

As the sun set, a ray of hope was rising from the country of a
thousand hills, a ray that cast its light towards saving the lives of those
affected by HIV/AIDS, malaria and tuberculosis.

There are some moments in life when you are simply proud. This
time, I was proud to be an African watching an event led by the Rwandan
Government, which involved both the Rwandan private sector and the wider
African private sector.

Certainly, the beam’s origin is a group of business executives
that converged at the invitation of Mrs Jeannette Kagame, the First lady of
Rwanda, for aPrivate Sector Summit dinner in Rwanda’s capital,
Kigali, on November 6, 2010.

After the 1994 genocide the successful rebuilding of Rwanda has
relied on multiple pillars, among them solidarity and responsibility. These
values have found memorable expression in the commitment undertaken in November
2010 by the Rwandan private sector, along with the African private sector.
Their joint action was guided by solidarity, social responsibility, common development
goals and the inspiration provided by the Government of Rwanda, which has led
the way by its commitment to improve the health of Rwandans. Such solidarity
and responsibility were vital in the ancient African setting, and should be
nurtured today and tomorrow, as we seek solutions to respond to African
challenges, particularly those that concern the health sector.

I would not be far from the truth in describing this initiative as
an indicator of tangible results that can be achieved when African leaders from
government and the private sector join forces: not only to fight HIV/AIDS,
malaria and tuberculosis on the African continent, but to contribute to a truly
global cause.

Africa bears more than 80% of the global HIV, TB and malaria
burden. This explains why about 60% of the resources of the Global Fund to
Fight HIV/AIDS, Malaria and Tuberculosis are allocated to Africa. 2010 is the
year of replenishment for the Global Fund. Organizations of Friends of Global
Fund across the world are advocating and mobilizing around this crucial year.
On November 6, 2010, at the initiative of Mrs. Janet Kagame, member of the
Board of Friends of the Global Fund Africa and wife of His Excellency Paul
Kagame, President of Rwanda, the Government of Rwanda hosted an African Private
Sector Summit as a fundraising event in favour of Global Fund replenishment.
Those attending the Summit include his Excellency President Paul Kagame, First
Lady Jeannette Kagame, and Michel Katzatchine, the Executive Director of the
Global Fund and Mr. Aigboje Imokhuede, Chair of Global Fund Africa.

During this event, $3 million were raised in the country of 1000
hills. The Rwandan private sector committed $1,200,000, the African Private
Sector an additional $800,000 and the Government of Rwanda $1,000,000. Compared
to how much the Global Fund needs, $3 million may seem like a drop in the
ocean. Yet this event holds significance that reaches far beyond a simple
monetary sum.

This contribution to the Global Fund aims at improving the lives
of the vulnerable and promoting health on the African continent. It reminds us
that each drop of water in the ocean is made by millions of years of
preparation. That means that what we see here is not a futile raindrop in a
sea, but rather an oasis in a desert that will and should continue to provide a
life-giving spring in the years ahead. We see Africans–African governments and
the African private sector–exercising their humanitarian duty and
responsibility by improving the wealth and the health of the African people.

The central lesson is that solidarity is paramount to attaining
national goals and building a national vision. Solidarity in this concrete
sense expresses the principle that those who have greater resources can pay
more, contributing to save the lives of those who have less, and thereby
enabling them to be healthy and productive citizens. Such solidarity
contributes to the development of the country and of Africa as a whole. Thus,
it ultimately benefits all. Such tangible solidarity exists in the Rwandan
system of health insurance, for example. That is how 92% of Rwandans enjoy
health insurance coverage that allows all to access the prevention, care and
treatment available in Rwanda when needed.

The contribution by Rwanda’s private sector to the Global Fund
replenishment has demonstrated that even developing economies can participate
and contribute to a global cause. Whether the strict monetary value is large or
small, lives are saved, and the beam of hope will shine on the lives of many in
Africa and beyond. It is true that Africans deserve to receive according to
their needs, but it is also true that Africans should contribute according to
their capabilities. Thanks to the commitment of the government of Rwanda and
the Rwandan and African private sectors, this principle is becoming a reality.

The Role of Social
Capital in Successful Adherence to Antiretroviral Therapy in Africa

This
Perspective co-authored with Niloo Ratnayake discusses the new study by Ware et
al. Published
in PLoS Medicine.

02
February 2009

In the
late 1990s and early 21st century, some public health officials in the Western
world believed that Africans would never be compliant with antiretroviral
therapy (ART) because the continent's uneducated, illiterate population was
driven by day-to-day concerns without much thought for the long-term future. On
top of this, many claimed that ART was a luxury for Africans and that the
complex disease would be too difficult for African doctors to manage in the
middle of nowhere with no water or electricity. Some went so far as to insist
that giving ART to a likely noncompliant population would create drug
resistance and were willing to sacrifice Africa for the good of global public
health [1].

However,
recent research has shown that levels of adherence to ART in sub-Saharan Africa
are in fact higher than those in North America [2]. Why are Africans with HIV
more adherent to ART than their counterparts in North America despite being
less educated about HIV and having more obstacles to overcome? A new study by
Norma Ware and colleagues published in PLoS Medicine sets out to answer this
complicated question [3]. This study investigates the surprising finding that
Africans would want to take drugs that would give them life and keep them
healthy. Anthropologically, this first question leads to another complex
question: Why is it that when things are successful in Africa the rest of the
world looks for a reason, but when things fail, there are few who question the
failure?

The New
Study

Ware and
colleagues asked patients, treatment partners (those who assisted patients in
their efforts to take antiretroviral medications), and health care providers
what the driving factors were behind adherence in three sites: (1) The Immune
Suppression Syndrome clinic at Mbarara University of Science and Technology in
Mbarara, Uganda; (2) the ART clinic of Amana District Hospital in Dar es
Salaam, Tanzania; and (3) the HIV/AIDS clinic at Jos University Teaching
Hospital in Jos, Nigeria. Patient interviews focused on experiences with taking
ART, clinic visits, and help from treatment partners. Treatment partner
interviews targeted the types of help that they give, feelings about being a
treatment partner, and opinions on their impact. Health care workers, such as
clinicians, nurses, and others, were asked to describe typical clinic visits,
ways adherence is discussed at these visits, and views of patient obstacles
towards adherence. The researchers also conducted observations of clinic
visits, with a focus on observing routine follow-up visits of patients taking
ART, counseling sessions, health education sessions, and the dispensing of
antiretroviral medications. In all, 158 patients, 45 treatment partners, and 49
health care workers were interviewed. There were 414 interviews and 136
observation sessions conducted across the three sites.

The
study shows that Africans overcome economic obstacles to get ART by begging and
borrowing money from friends, families, and even their health care providers.
They may choose to use money for transportation for their clinic appointments
over food for them or their family, over school fees for their children, and
over treatment for their sick child. Patients without money would take their
medications without food despite the increased risk of side effects and would
walk to health clinics despite long distances. Health care providers also made
sacrifices by keeping their offices open longer to accommodate patients who
arrived late and gave food, money, and even loans to needy patients.

The
study also shows the significant impact of social responsibility upon
adherence. Families and friends often help finance health needs, but this
assistance becomes more difficult to justify if it is believed the patient is
near death or incurable. Treatment partners insisted on adherence to ART by
those they cared for because it made the treatment partner's burden lighter.
The treatment partners' help created an obligation to patients to be adherent.
Some health care providers threatened to discontinue giving treatment to
nonadherent clients, further emphasizing the social responsibility patients had
to remain adherent.

Public
Health Implications

Ware and
colleagues' multi-country, multi-setting study used a methodology of
interpersonal interaction that allowed people to talk simply to the
researchers, without complicated study designs getting in the way. Instead of
coming with experts and boxes to check, the researchers captured the viewpoint
of the patient, treatment partner, and grassroots-level health care worker. The
findings show the importance of social capital (the connections between people)
and reveal that social responsibility in Africa pushes people to be “good”
(adherent) patients. Social capital has been used in other countries such as Rwanda,
where those who want treatment must come to the clinic with a relative or
members of their association.

Those
who have truly been working in Africa should not have learned anything new.
Social capital can be easily seen in day-to-day health care work. This new
study will, however, hopefully change the way the rest of the world views
Africa. The study proves that human rights activists were correct in believing
that giving ART in underdeveloped settings does not put the world in danger.
When future myths about Africa are presented, people can point to this study to
show that the uneducated, illiterate, and poor still want to survive, perhaps
even more than those in Europe or the United States. Although this study does
not change policies and will not affect future clinical decisions, it can be a
useful tool to create support for access to treatment in Africa.

Social
coercion in Africa is high because people are more responsible for each other.
Yes, Africans want to live, but more than that, they want to keep their
relationships alive. Patients living with HIV in North America often have
negative experiences and complicated backgrounds, such as traumatic events and
mental illness, with little social support, and they face a great deal of
stigma [4]. Social capital is less strong in the United States than in Africa
as people in the US tend to be more individualistic and therefore less focused
upon and connected to the group as a whole. There is less concern about others
and less of a feeling that others are concerned about you. Ware and colleagues
state that: “In North America, adherence to ART for HIV/AIDS has been
interpreted as the product of information, motivation, and behavioral skills
operating at the individual level.” In other words, the driving factor for
Americans to take their drugs is not social responsibility, but
intellectualization of what to do to remain alive. Patients take the drugs they
are given for themselves and not for others. Therefore, when a patient becomes
depressed, adherence often declines. Research has shown that depressed people
living with HIV progress to AIDS faster than those who are not depressed, due
in part to nonadherence [5]. In Africa, on the other hand, taking prescribed
ART is a community effort. Even when patients no longer care for themselves,
they continue to take the medication for the community around them.

Next
Steps

Having
clearly established the importance of social capital in promoting adherence to
ART, future studies should focus both on its protective effects outside of the
scope of HIV/AIDS and on how to maintain social capital while improving
economic development, which can bring a more individualistic way of life. A
developed economy provides an environment that allows the growth of
individualism, while the poor tend to depend on their community for survival.
Social capital can be a useful tool in promoting adherence to medications in
patients with chronic diseases, who are at higher risk of depression than the
general population [6]. As countries in Africa become more economically
developed, it will be increasingly more important for them to actively find
tools to maintain their social capital.

In 2010, a nationally sponsored study to test the safety and
efficacy of the system was initiated: http://clinicaltrials.gov/ct2/show/NCT01150370.
Results showed its potential to revolutionize male circumcision as an HIV
prevention method. And a new study is currently under way in Rwanda to compare
it to surgical circumcision for rapid scale-up of male circumcision in resource
limited setting:http://clinicaltrials.gov/ct2/show/NCT01284088.

Fight for Cervical
Cancer Prevention, Diagnostics and Treatment in Africa!

21
February 2011

Today, I have been reflecting on the progress the world has made
in the fight against infectious diseases. Even though there is a long road
ahead, there are many achievements we can be proud of. In my country, Rwanda,
we have decreased the rate of deaths due to malaria by more than 65% since
2005. We are now providing universal access to anti-retroviral therapy (ART)
for all those diagnosed to be in need of treatment, a total of over 83,000
people. Rwanda currently has multiple hygiene campaigns; and has provided
60,000 Community Health Workers with antibiotics (Ampiciline), oral rehydration
solution, and training on how to treat digestive and pulmonary diseases at
home. Through these interventions, we are sure to continue to make progress in
tackling communicable diseases.

In Rwanda, now that morbidity and mortality due to infectious
diseases have both decreased, we are looking to take a step forward and tackle
the other serious causes of death. According to the WHO, non-communicable
diseases (NCDs) are responsible for 25% of mortality in our region of the
world. For the past two years, the Ministry of Health of Rwanda has been
considering various initiatives specific to NCDs. Cancer is one of the top
killers among this category of disease. It is a leading cause of death
worldwide accounting for an estimated 7.9 million deaths in 2007 alone. Knowing
that over 70% of these deaths occur in low- and middle-income countries, where
resources available for prevention, diagnosis and treatment of cancer are
limited or nonexistent, I argue that it is time for us to focus on a strategy
to reduce the burden of NCDs. The challenge will be to do so without reducing
our energy currently put into fighting communicable diseases.

Among women, cancers of the breast, uterus, cervix and ovaries
represent the most common cancers diagnosed. Until recently, there was no
certain way to prevent these cancers. Yet now one of the most common causes of
cancer among women in our region, cervical cancer, is preventable with a simple
vaccination. As such, here in Rwanda in 2009, under the leadership of President
Paul Kagame, we began to work on a plan to provide universal access for primary
prevention of cervical cancer by vaccinating our girls with the HPV vaccine
before any sexual intercourse. Now we have finished our strategy for national
cervical cancer prevention, screening and treatment, and we are strongly
pushing global leaders to help make our plan a reality.

Our program is very simple: One full package for girls (primary
prevention = 3 doses of HPV vaccine before any sexual intercourse) and One full
package for women (screening technology = HPV/DNA technology and access to
treatment at ages 35 and 45). The best place to implement the vaccinations will
be where our girls and women are living. Because we are experienced in offering
our population a very high vaccine coverage, we are confident in the plan to
provide universal coverage for cervical cancer prevention by vaccination. In
the case of malaria and HIV, Rwanda has effectively implemented diagnostic and
treatment capacities from communities to referral systems. Rwanda has
introduced new vaccines and effectively achieved high coverage of these
vaccines; we were the first country to introduce pneumococcal vaccine in
Africa. Now we have built on our existing capacity to implement preventive,
diagnostics and treatment measures at all levels of care, and have used lessons
learned to ensure the same for the management of cancer. Therefore, we need the
world to believe that such a medical intervention and such technologies should
be accessible to Rwandan women; and to believe that we can do this just as we
have successfully implemented myriad other public health programs.

Unfortunately, some influential partners contradict their mandate
by trying roll us back. This situation reminds me of the late 1980s when
activists proposed to make ART accessible to African people living with AIDS.
Many argued against this – particularly deliberating about whether African
health professionals would be able to manage such complicated treatment instead
of working with them on how best to implement such an intervention in
resource-poor settings. In the fight against cancer, we will build on the
lessons learned from the successful HIV and malaria programs already firmly
established in Rwanda. So let’s all push together to make it happen today.

Human
beings have a fundamental right to health, which must be equally distributed to
all. To be able to provide the prevention, care, treatment and rehabilitative
services needed for its population, Rwanda has embarked on an ambitious journey
to transform its socio-economic situation by changing its economy from an
agriculture-based to a knowledge-based economy. In this context, Rwanda has
identified the use of science and technology as a key tool for achieving our
socio-economic transformation and reaching the MGDs. Although a high tech
strategy may appear inappropriate for the health system of a developing
country, this is is not applicable to Rwanda because our health sector ICT plan
is integrated into two master plans: our health sector strategic plan and our
national ICT plan. We know that e-Health is vital in order to create an
effective and sustainable health system, as it will help us solve challenges in
our health system, such as the lack of infrastructure and the shortage of
professionals (since roads are still a problem in some remote areas, sending
information, plans, and reports by ICT saves time and money).

Another
reason why ICT for E-Health should be developed is because the right to health
cannot be separated from the right to information, and the use of new
information and communication technologies is the most accurate and timely way
to provide information.

A good
flow of information concerns four categories in the health sector: the
patients, the policy makers, the care providers and the program managers. When
it comes to patients, they need to be educated on their health needs and on
how, when, and where to seek proper care. Also, once on treatment, patients
should know why it is important to go for timely medical follow up appointments
and be compliant to treatment, since it not only aids their recovery, but also
helps to avoid dangerous resistances to epidemic diseases like HIV. Patients
would be informed of these things by making ICT tools available to health
professional at all level: community health workers would use phones, while
central and district managers, health centres, district hospitals and referral
hospitals would use web-based tools. For policy makers and program managers,
ICT is important because it helps to design health policies and programs that
are informed by evidence and based on accurate information. In general, the use
of ICT has proven to be the more effective, secure, rapid and accurate way to
serve patients and program managers. This is why the Government of Rwanda has
put ICT as a top priority for its health development and recognizes that there
is an urgent need to build e-Health capacity.

Many
applications of E-health have already been provided. One good example are the
web dialogues, which are good entry points for information access and exchanges
between professionals and semi professionals who work in remote areas, and
therefore have difficult access to journals and books. It is also a tool of
sensitization, reflection, idea expression, and innovation. Since it is
virtual, it does not require physical infrastructures and costs nothing.
Through the exchange of biological and immunological patient information,
Xrays, echographies, etc, clinicians can receive ideas, confirm diagnoses and
make correct decisions. For example, Harvard’s Global Health website connects
Rwandan health professionals to counterparts in other countries, such as the
United States, Haiti, and Peru, and allows for free communication between these
countries on several levels. ICT also allows for the horizontal exchange of
information between policy makers, programs managers, and community workers at
the grassroots level. It also allows for vertical exchange between those three
categories, thereby breaking barriers to knowledge and communication.
Such information flows create an international family of global health workers
and help to bring communities on board with the decisions that concern them.
These communication exchanges can take on many different models so countries
can choose which one best suits them. As a result, one gains time by quickly
building on the experience of peers around the world, and this web-based free
information can dramatically improve national and global health.

Without
ICT all Rwanda sub programs in the health sector would be unmanageable, since
it greatly helps the day to day work of health care providers. For example, the
healthcare financing system is web based and manages more than 90% of the
Rwandans enrolled in health insurance, along with the performance based program
in the 480 health facilities. Rwanda’s ART program, which provides
antiretroviral therapy for 70% of people living with AIDS who need them, is
also managed via web based technology. ICT also helps to gain data for Rwanda’s
localized MDG report, since community health workers and health professionals
do active case finding of fever and malnutrition, perform maternal audits, and
collect information on all maternal deaths in the country via this technology,
in order to better understand why young healthy Rwandan women can be at risk of
death during pregnancy or delivery. Also, many other programs in Rwanda have
web-based management, such as health surveillance, public health reporting,
drug procurement, drug tracking, the blood bank, and E-learning. The big
challenge is coordinating ICT tools so that these web based management systems
are efficient and have synergy.

All of the
above reasons show why the Government of Rwanda has put ICT as a top priority
in our health development, as it recognizes the urgent need to build e-Health
capacity in order to provide and maintain highly effective, reliable, secure,
and innovative information systems to support clinical decisions, patient
management, education and research functions within Rwanda’s health sector. This
approach will be crucial in enabling the sustainability of an integrated and
coordinated healthcare system in Rwanda that will efficiently provide
high-quality, gender, geographical and age balanced services.

The last
advantage of using an ICT approach is that we save trees since we are saving
the paper used for plans, reports, files, mails, etc… At this time when experts
recognize the danger of global warming to the Earth, “saving CO2” environmental
programs should also award the use of ICT by the Government of Rwanda!

Mental Health is a
Basic Human Right to Fight For

13 December 2009

Disruptive Women in Health
Care Blog

A few days
ago the world celebrated Mental Health Day, and more recently it was the Human
Rights Day, as such I have decided to post a reflection on the rights of all
people to access mental health care as a part of the access to health care as a
basic Human Right. I especially dedicate this reflection to the issues
surrounding access to quality mental health care services for women.

Unfortunately,
in the majority of the developing world, mental health is not an issue that is
given adequate attention. However, if we take the definition of WHO, mental
health plays as important part in overall health as the physical aspects do. To
improve mental health, governments have to create a well-trained and
well-equipped workforce to care for mental health and ensure that the funding
and human and physical infrastructures are available. This will help to
increase access to mental health care, but should be completed by making drugs
available, like psychotropic drugs. Many of these medications are not so
expensive and can be part of public essential drugs available at public health
facilities. It is a matter of paying attention to the problem.

Also, the
general population should be educated via mass media campaigns so that they
will have less fear and a better understanding of mental health diseases and
those who suffer from them, causing mental health patients to suffer from less
isolation, stigma and discrimination. This can be done by partnering the
government with civil society organizations to improve the public education on
this issue through TV, radio, speeches, billboards and community events.

Both of
these points are vital and necessary if we wish to improve the care of people
who suffer from mental illness,
because they will encourage the community to send people for care when mentally
ill, and when the patient arrives, the health care providers will be ready to
give proper care.

This is
the system that the Government of Rwanda is creating by having one psychiatric
nurse in each district hospital working in an integrated manner with hospital
personnel, and by training general practitioners in the diagnosis and treatment
of simple mental diseases and in the identification of severe ones so that such
patients can be transferred to the national referral hospital for mental
health. We also have some psychotropic drugs available as essential drugs, but
we still have a long way to go to ensure that every Rwandan in need of mental
health receives it.

An
extremely important area of mental health care for women is trauma due to
conflict situations, where many women are devastated because of rape and other
sexual violence, as these health issues are often neglected. Mass rape has been
used as a tool for war for centuries, and can be found in modern history as
well: from the rape by German and Japanese armies during World War II, to the
use of systematic rape and deliberately infect women with HIV during the
Rwandan 94 genocide against Tutsis; this: from the rape of women during the
Kosovo conflict, to the current use of rape to intimidate and humiliate women
in the eastern regions of the Democratic Republic of Congo and through the
devastation of their genital organs. For these women, international organizations
should play a bigger role, since most of the conflicts are predictable and
usual time for rape, sexual abuse and
violence and psychological traumas.

In post
conflict situations such psychological destruction needs specific attention to
rebuild mental health and care for psychological reconstruction as a priority.
Instead, the thousands of individual women suffering from this type of trauma
are totally neglected and suffer in silence. Furthermore, in some countries
these women additionally face stigma because of forced sex and pregnancy out of
marriage, and are sometimes even forced to leave their households and villages
because of that – doubling their trauma. In this manner, the communities who
should be helping these women instead end up being on the same side of the
perpetrators of this violence. For the prevention of mental health illness in
women post wartime sexual violence, we must do massive behavior change campaigns
for tolerance in countries recovering from wars. That was we did and
still do in Rwanda. If not, these women will be denied their basic human rights to gender non-discrimination,
to live without violence, and to access care for mental illness and other
health issues like STIs, HIV, and genital organ damage.

Profile

is a pediatrician who has served 14 years in high-level government positions across the Rwanda Health Sector. She is currently a Senior Lecturer in the Department of Global Health and Social Medicine at Harvard Medical School, a Professor of the Practice of Global Health Delivery at the University of Global Health Equity in Rwanda, and an Adjunct Clinical Professor of Pediatrics at Dartmouth College's Geisel School of Medicine.